Field Guide to the Arrhythmias

171 Pages·2013·3.414 MB·English

by  Ellis W. Lader(auth.)

FIELD GUIDE TO THE
Arrhythmias
Tomyfamily
FIELD GUIDE TO THE
Arrhythmias
ELLIS W. LADER, MD, FACC, FAHA, FACP
MidValleyCardiology,Kingston,and
AdjunctAssistantProfessorofClinicalMedicine
NewYorkUniversitySchoolofMedicine
NewYork,NY,USA
AJohnWiley&Sons,Ltd.,Publication
Thiseditionfirstpublished2013(cid:2)C 2013byJohnWiley&SonsLimited
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LibraryofCongressCataloging-in-PublicationData
Lader,EllisW.
Fieldguidetothearrhythmias/EllisW.Lader,MD,FACC,FAHA,FACP,MidValleyCardiology,adjunct
assistantprofessorofclinicalmedicine,NewYorkUniversitySchoolofMedicine,NewYork,NY,USA.
pagescm
Includesbibliographicalreferencesandindex.
ISBN978-1-118-38609-5(pbk.:alk.paper) 1.Arrhythmia. I.Title.
RC685.A65L332013
616.1(cid:3)28–dc23
2012047266
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1 2013
Contents
KeytotheArrhythmias,insidefront/backcovers
Preface,vi
Acknowledgments,viii
Abbreviations,ix
PART1: THERHYTHMS,1
NormalSinusRhythm,3
Preexcitation,4
SinusBradycardia,6
SinusTachycardia,7
SinusArrhythmia,8
WanderingAtrialPacemaker,9
MultifocalAtrialTachycardia,10
JunctionalRhythm,12
Asystole,14
HeartBlock:FirstDegree,SecondDegree(MobitzIandII),andThird
Degree(Complete),16
PrematureBeats(BlockedandOtherwise),20
AtrialFibrillation,23
AtrialFlutter,25
Supraventricular(ParoxysmalAtrial)Tachycardia,28
PacemakerRhythms,30
VentricularTachycardia,33
AcceleratedIdioventricularRhythm,36
ProlongedQT/TorsadesdePointes,38
VentricularFibrillation,41
PART2: MULTIPLECHOICEQUESTIONS,43
v
Preface
Iftheinnocentoruninitiatedweretowanderthroughthecardiacunit,telemetry
unit,orinfactthroughanyunitwhereECGmonitoringisinuse(wewillstick
withtheEnglishElectroCardioGramspelling),heorshewouldlikelyencounter
rhythmswhichwereunfamiliar.Itisevenpossiblesuchrhythmsmightberudely
thrustintoone’sfacewitharequesttoevaluatethemoreventakedrasticaction:
“Should I shock him?” or “Do you think this is Mobitz I second degree SA
exit block?” In fact, traveling through a unit in such fashion may be likened
to a wanderer strolling through a forest, unsure of the names of the trees or
wildflowers,orthesignificanceofcertaintracks(seebelowfigure).
TrackofBrotozoumgiganteum,generallybestavoided(withsize11humanfootprints,for
scale)
Whenoneisinthewoodsitgreatlyincreasesthepleasureandpossiblythe
safetyofthetripifthehikerhasaFieldGuidewhichenablesthewandererto
safelyidentifythevariousfloraandfaunaencounteredalongtheway.Itshould
thentakethereaderjustamomenttorealize,carryingthemetaphoronlyalittle
further,theneedforasimilarFieldGuidetotheArrhythmias,asonenavigates
thevarioushazardsofthetypicalcardiacunit.Hencethiswork.
This Guide is intended for the student, the casual explorer, making his or
herfirstforaysintotheRealmoftheCardiacMonitor.1 Atrainedcardiologist
won’tneedit,beingabletoidentifyanarrhythmiausingonlyafragmentofa
1Weassume,gentlereader,thatyouhavemasteredtheverybasicsoftheECG:i.e.,youcan
tellwhichsideoftherhythmstriporECGisup,knowthattherhythmisrecordedfromleft
toright,canidentifytheP,QRS,andTwaves,andknowtheirnormalwidthsandintervals.
Otherwise,Ihaveincludedtwoofmyfavoritereferencesbelow,oryoucangoasktheHead
Nursepolitely.DubinD.RapidInterpretationofEKGs:AnInteractiveCourse,6thedn.Tampa,
FL:CoverPublishingCo.,2000.WagnerGS.Marriott’sPracticalElectrocardiography,11thedn.
Philadelphia,PA:LippincottWilliams&Wilkins,2007.
vi
PREFACE vii
Pwave,akintoabotanistwhoonlyneedsapetalandafewstamenstoiden-
tifyasubspeciesofgoldenrod.Afewcardiologists,surprisingly,haveexpressed
displeasurewiththisGuide.Theyclaimeditwastoooffbeatandirreverentfor
theirserioustastes.Personally,IsuspecttheysecretlyfeartheGuidemaydoaway
withtheneedfortheirservices!Actually,exceptforthefewremainingclinical
cardiologists,manyofthemmightactuallyneedabasicguidethemselves.Some
oftheinterventionalistsIknowhaven’tlookedatanECGinyears.
But seriously, the cardiac unit is a jungle, inhabited by fierce nurses, killer
intensivists,maraudingattendings,variousflesh-eatingspecialists,sickpatients,
andlotsofarrhythmias.Beingabletoquicklyandeasilyidentifythearrhythmias
oneislikelytoencounterthere(oranywhereelse)islikelytomakeone’stravels
theremoreenjoyableandprobablysafer.SogatherupyourGuide,bringalong
yourbutterflynet,magnifyingglass,calipers,andanextrapairofsocks,andlet’s
getstarted!
Acknowledgments
I would like to acknowledge the invaluable electrocardiographic teaching I
received early in my training from Dr. Bertha Rader, the Queen of Electro-
cardiographyatBellevueHospital,NewYork.ImustalsothankAliceLopezand
Pat Curtis, the giants of our practice’s and Benedictine Hospital’s arrhythmia
services,alongwithourICUandstep-downunitnurses,andmonitortechsin
the“warroom,”allofwhomhelpedsupplytherhythmstripsandinspiresome
ofthescenariosthatmadethisworkpossible.
viii
Abbreviations
AIVR Acceleratedidioventricularrhythm
AV Atrioventricular
CCU CoronaryCareUnit
CPR Cardiopulmonaryresuscitation
CT Computedtomography
ECG Electrocardiogram
ICU IntensiveCareUnit
PAC Prematureatrialcomplex
PVC Prematureventricularcomplex
SVT Supraventriculartachycardia
VT Ventriculartachycardia
ix
PART 1
The Rhythms
FieldGuidetotheArrhythmias,FirstEdition.EllisW.Lader.
(cid:2)C 2013JohnWiley&Sons,Ltd.Published2013byBlackwellPublishingLtd.